GW1--05601_Well Construction - GW1_20240916

I Print Form 11
".WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Lloyd Mares 14.WATER ZONES . !
WeIlContractorName FROM - TO -
DESCRIPTION
ft. ft.
2547-A
ft. ft.
i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Register Well Co.,InC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 138 ft• 4 : i°. .40 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL •
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
N
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural OMunicipal/Public 138 ft. 158 ft. 4 i"' .016 pvc
11 Geothermal(Heating/Cooling Supply) IResidential Water Supply(single) ft. ft. in.,
"[Industrial/Commercial Residential Water Supply(shared) 18.GROUT
X'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - 0 ft. 20 ft. hole plug pour
NI Monitoring Recovery - ft.. ft.
Injection Well: -
ft. ft.
®Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
II Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*:Aquifer Test 0 Stormwater Drainage tt 6 ft. 4t55g ft. #2 '' , pour
®Experimental Technology f. Subsidence Control ft. ft. ' I
i
®'.Geothermal(Closed Loop) . Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness•soil/rock type,grain size,etc.)
el Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. 5 ft. sand :
4.Date Well(s)Completed:08/30/24 Well ID# 5 ft. , 63 ft. clay
.ft. . _04 ft. -:s e f "' a r,�.
sa.well Location: 63 -, rock:10•.in soft ti +�� ', �'�3
Doug-Batchlor - 64 it 68 ft• clay r,.��[�..�•l�. -
Facility/Owner Name Facility ID#(if applicable) 68 ft-• 76 ft.: clay and sand S E P- 1 b .20 Z4
114 Cardinal Crest Dr Wallace NC 28466 76. ft 78 ft rock 2'hard ,,,;ew.,!-,01.1e ;
yTn is rrm.+.2. ,, �'`��
Physical Address,City,and Zip 78 .ft. 90:,' ft. • sand-and clay Ld6�Cv.20G
Duplin 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.760746 -77.9264 W LL.LL 7i/1.4 09/11/24
X - Signature of cti�ell Contractor Date
6.Is(are)the well(s)0Permanent or ['Temporary
By signing this form,1 hereby certfY that the'well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: II]Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. '
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 158- (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2@I00') construction to the following: '
10.Static water level below,top of casing:20 (ft.) Division of Water Resources,Information Processing Unit,
'If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 3/4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form-within 30 days of completion of well
12.Well construction method: •' construction to the following: I:
(i.e.auger,rotary,cable,direct push;etc.) Y I
s.
• Division of Water Resources,•Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636-Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm).50 Method of test:air -24c. For Water Sunnly&Injection•Wells:. In addition Jo sending the form to
• the address(es) above, also'submit one copy of this form within 30 days"of
13b.Disinfection type: hth Amount: 8 OZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, I - Revised 2-22-2016

z,
CUSTOMER 0
L : 6 WN ? 041-ACI4L— ADDRESS: rsr a r'YZA..-.,- J ,IP7'......57L'
.....)
'..,:•„
THICKNESS FORMATION THICKNESS FORMATION
FROM TO (CLAY, SAND.ROCK,ETC.) FROM TO,- (CLAY.SAND.ROCK.it.
I
0
7
trtt
„0-
•- /
i
7
• t i , it , 1,2,,,,..e t, i 0'f..,,,, „SC4-:/. ,-.
? ,,,,..,0-..,..) 1,-, i
I I,
•
., %
, .
Ik,
- • 4
' . 0 1 —
'-'..` ',_'.
( /
/ ,L
,,-)--.4 ';'' ) ', f
, 1, , . , _ • - --. ,, ', •; •„' • • ,..:(j,.,
,,.,,,...,.. ,f :/e , r.:,r, ,‘; -s' ,,_' 11 ; -,:. ,i. .,, 4,
90 a/
e'r
... i ,
I,:;"2., 4 .6.til" --,1- 5,,, ,,A e,e[,,,,.. /Cr/re-7
-. I . ..
ft,.-4, 1 it 0.C2
- ..
'
•
' ,
. ,5' ,,/ ...1 ,,,,,, .,
-' I( oz-ft ,-;4,h-'1
1 - • ,,,„ . ..._. , t
e'
!!.:t /i 4,... _1,1)e. r'' /......e 1,,,,,..,, ..
e ;
'V
i
n..--
_ ..._
i„
/
•-..'‘''- ' 14.' ''l te.,e7 - 1 ', .
A
./.,` • ' e
, i
,, ) ,
,
r,,
N :
1